Healthcare ForumRemoving Private Activity from

Public Hospitals & its Impact on the Healthcare System

Society of Actuaries

1

Mr Martin Varley

Secretary General 3rd December 2019

History of Health Reform

• Track record: unimplemented reports and strategies

• Fitzgerald (1960s), Hanly (2003), VFC Mental Health (2006)

• Health Boards, HSE, Integrated Areas, Hospital Groups, CHOs, UHI

• Removal/Reinstatement of HSE Board

• Regional Integrated Care Organisations (RICOs): Health Boards revisited

• Rationalisation, colocation, reconfiguration, integration …

• Strategy, Planning, Management churn

• Indicator of dysfunctionality 2

2017 Sláintecare Recommendations

3

• First decade cost: €20bn plus €3bn transitional

• Second decade cost: €28bn + inflation

27%

26%17%

15%

10%

4%

1%

Sláintecare Year 10 Costs (%)

Acute Hospital Expansion

Primary Care Expansion

Social Care Expansion

Reduce/remove charges

Expand Health & Wellbeing

Mental Health Programmes

Dentistry Expansion

Sláintecare Qualifications & Unintended Consequences

4

“The Committee acknowledges that removing private care from public hospitals will be complex. It therefore proposes an independent impact analysis of the separation of private practice from the public system with a view to identifying any adverse and unintended consequences that may arise for the public system in the separation. Given the acknowledged need to increase capacity in the public system, it is important that any change should not have an adverse impact on the recruitment and retention of consultants and other health professionals in public hospitals.”

Sláintecare & Capacity Expansion??

5

• Expand Hospital Activity????

o Replace private insurance income year 2 – 10: Year 10 cost €649m

o Increase consultant numbers by 593 (+20%): Year 10 costs €119m

Other Capacity Expansion Needs

6

Bed Capacity

Deficits

o 2,600

additional

public hospital

beds (€2.6Bn)

o 4,500

Community

beds (€4Bn)

ICU Capacity

o Need 330 more ICU beds (€412m)

Equipment & Facilities

o Replace obsolete

o Expand facilities as inadequate

o €3.64bn to replace equipment (2017-2021)

2019-2021 Capital Plan

7

• HSE to provide

480 new

hospital beds

between

2019-2021

• This is 100 less

beds over each

of 3 years

de Buitléir Recommendations

8

• Legislation so public hospitals exclusively public patients from conclusion of 10 year Sláintecare implementation period

• New Consultant appointments Sláintecare Consultant Contracts – public only

• Restore pay parity to pre-2012 levels for all Consultants

• Offered “contract change payment”

• All existing contracts 39 hrs

• Declining Salaries A → B → B* → C ??

Consultant Vacancies and the Recruitment

and Retention Crisis

10

Source: NTPF (2013 - 2019)

• 567,200 in October

• ↑ 51,059 (9.9%) in 2019

• ↑ 189,709 (50%) in 5 years

• 500 Permanent hospital Consultant posts can’t be filled

Outpatient Waiting List (March 2013-Oct 2019) Capacity Deficits

384,632

300,752

375,440

567,211 (Oct-19)

300,000

350,000

400,000

450,000

500,000

550,000

600,000

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

May

-16

Jul-

16

Sep

-16

No

v-1

6

Jan

-17

Mar

-17

May

-17

Jul-

17

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

No

v-1

8

Jan

-19

Mar

-19

May

-19

Jul-

19

Sep

-19

Total Outpatients Linear (Total Outpatients)

11

Consultant Vacancies and the Recruitment and Retention Crisis

• 42% fewer medical specialists than EU average

• Over 500 posts vacant or filled on a temporary basis

Specialist medical practitioners per 1,000 population in EU in 2018

(or nearest year)

Source: Eurostat

4.95

3.51

3.25

3.1

2.75

2.62

2.49

2.47

2.09

1.97

1.76

1.44

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Greece

Lithhuania

Germany

Italy

Czechia

Austria

Estonia

Hungary

Switzerland

Spain

Portugal

Latvia

EU Average

Slovenia

Sweden

UK

Luxembourg

Norway

Netherlands

Poland

Finland

Belgium

Denmark

France

Ireland

12

Specialist medical practitioners in Ireland per

100,000 population as a percentage of the EU

average (2016 or nearest year)

• 1/4 to 1/2 in many specialties

• UCC at Connolly Hospital only open for 1/3 of planned hours

82 82

6661

5855 53 52 51

48 46

3732 32 30

25 23

0

10

20

30

40

50

60

70

80

90

100

% of EU Average

Source: Eurostat

13

Public Hospital Inpatient and Day Case Beds, and Population Growth 2008 to 2019

Source: Department of Health Open Beds Report Sept 2019; Health in Ireland: Key Trends 2017, DOH; CSO

Increased Acute Hospital Capacity Requirements

13,584

13,141

12,847

12,630

12,38612,43212,48612,499

12,73212,835

13,09613,231

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 YTD

Total Inpatient and Day Case beds 2008-2019 YTD

4,485.10

4,533.404,554.80

4,574.904,593.70

4,614.704,645.40

4,687.80

4,739.60

4,792.50

4,857.00

4921.5

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Total Population 2008-2019 (April)

• Population ↑ 9.7%

• Bed capacity ↓ 2.6%

• 12.3% increased deficit

• 22% ↑ (273,433) in inpatient and

day cases performed

14

Source: NTPF (2013 - 2019)

• ↑ 24,089 (55%) in 7 years

Total Inpatient and Day Case Waiting List (March 2013-Oct 2019)

47,413

44,870

68,086

86,111

67,511 (Oct-19)

40,000

45,000

50,000

55,000

60,000

65,000

70,000

75,000

80,000

85,000

90,000

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

May

-16

Jul-

16

Sep

-16

No

v-1

6

Jan

-17

Mar

-17

May

-17

Jul-

17

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

No

v-1

8

Jan

-19

Mar

-19

May

-19

Jul-

19

Sep

-19

Total Inpatients/day cases Linear (Total Inpatients/day cases)

16Source: OECD.Stat; Eurostat

Our hospital bed capacity:

• 31% below EU average

• Regular bed shortages

• Rationing care

• Delays

Hospital beds per 1,000 of population in EU, 2018 (or nearest year)

7.27

6.84

6.02

5.49

5.47

5.45

4.98

4.91

4.85

4.69

4.27

4.2

4.11

4.02

3.7

3.6

3.45

3.43

3.3

3.25

3.09

2.92

2.8

2.77

2.62

2.43

2.44

2.11

2.04

0 1 2 3 4 5 6 7 8

Bulgaria

Romania

Germany

Croatia

Lithuania

Austria

Belgium

Slovak Republic

Poland

Malta

Hungary

Slovenia

Czech Republic

EU28

Luxembourg

Greece

Estonia

Cyprus

Latvia

Portugal

France

Netherlands

Finland

Ireland

Italy

Spain

Denmark

UK

Sweden

19

• Over 500 Vacancies + 108 non-specialists in Consultant posts since 2008

• “Jeopardising patient safety” – Justice Peter Kelly

• Medical agency spend 2012-2018 ↑€57m p.a.

• Agency Consultant costs up to three times New Entrant Permanent Consultant Cost

• New Entrant salary is up to 51% below colleagues

• Failed to fill 38% of posts advertised 2015-2017

• Not competitive – salaries in Australia, Canada and US up to 48% above non-new entrant salary

• Annual Medical Indemnity costs quadrupled between 2013-2018. Increase of €184 million

Consultant Vacancies and the Recruitment and Retention Crisis

21

Source: INMO Trolley Ward/Watch

• 108,000 admitted patients treated on trolleys in 2018

• Nearly double ‘national emergency’ level of a decade earlier

Number of patients treated on trolleys annually (2008 – 2018)

59,43563,713

75,859

86,481

66,308 67,863

77,091

92,998 93,62198,981

108,227

0

20,000

40,000

60,000

80,000

100,000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Nu

mb

er o

f P

atie

nts

22

Source: INMO Trolley Ward/Watch

• Year round problem

• July 2019 (9,439) a record for the month – ↑ 33% on July ’18

• August 2019 (9,562) highest ever for the month – ↑ 10% Aug ’18

• September 2019 (10,641) – worst Sept on record – ↑ 36% Sept ’18

• Oct 2019 (11,452) – worst Oct and 2nd worst month ever – ↑ 26% Oct ’18

Trolley Analysis January/July 2008-January/July 2019

23Source Health Service Performance Profile January to March 2019

• Symptomatic

Breast Disease

Clinics 44% <

target

• Rapid Access

Clinics for Prostate

Cancer patients

21% < target

Delays in Accessing Treatment resulting in missed Cancer KPI targets

Media Coverage

de Buitléir Report Terms of Reference

25

“The Review Group will examine and enquire into the effects of the removal of private activity from public hospitals and will specifically examine potential benefits and potential adverse consequences, including any unintended consequences that may arise, in the removal.

In particular the group will examine and consider…

• possible impacts, both direct and indirect, immediate and over time, of removing private practice from public hospitals, including but not limited to impacts on: access; hospital activity (including specialist services); funding; recruitment and retention of personnel; and any legal or legislative issues that might arise.”

Sláintecare and the de Buitléir Report

26

• €20bn to implement Sláintecare in first decade (€28bn thereafter)

• Confirms need for more Consultants and beds

• Removing private care from public hospitals to cost €6.5bn over 10 years (€8bn thereafter)

• In reality loss in private health insurance income will not be replaced

• Exacerbate Consultant recruitment and retention crisis & hospital capacity deficits

• Ideology v Pragmatism

27

Real World Challenges on Hospital Frontline

• Hospitals crumbling after a decade of cuts (€1.88bn health capital cuts 2009-2019)

• Health capital budget in 2019 €667m, including €325m for acute hospitals

• Delays in bed capacity ↑ by 2,600 beds before 2027

• Delays in community beds ↑ by 4,500 beds by 2027

• Rationing of care, growing waiting lists, and trolley crisis

• Nearly 50% population with PHI: Capacity & Delays

28

Real World Challenges on Hospital Frontline

• Need separate additional funding for National Children’s Hospital (€2Bn vs €0.63Bn estimate)

• National Children’s

Hospital Cost

Overrun:

o €100m in 2019

(€25m from HSE)

o €107m in 2020

o €120m in 2021

o €150m in 2022

• Ongoing problem

• Cost of Relocation of

3 Dublin Maternity

Hospitals

29

Real Strategic & Hospital Needs

o Fill all approved Consultant posts on a permanent basis

o ↑ Frontline capacity to treat people awaiting outpatient appointments, and inpatient and day case elective procedures

o ↑ Public acute hospital bed capacity

o ↑ Funding to address capacity deficits

o Meet KPI targets for cancer care, surgical procedures and key aspects of patient care

30

Solutions to Frontline Problems

• Resolve public hospital access crisis

• Insufficient public hospital capacity

o Record waiting lists

o Record numbers on trolleys

• All patients in public hospitals are public hospital patients who need care without current delays

31

Sláintecare & de Buitléir Reports

• Unintended consequences

• Loss of €6.5Bn PHI per decade

• Won’t be replaced

• Substantial other investment and operating costs

• Already lagging behind NDP 2,600 hospital bed timetable

• Counter productive – Prolonging Access Crisis

32

Sláintecare & de Buitléir Reports

• 2.22m (45%) PHI members

• Increased by 64,000 (3%) since May 2017

• Market segmentation

• 10% PHI members with Public Hospital cover only

• 50:50 reliance Public & Private Hospital care

• Little or no capacity freed up in Public Hospitals

33

Removal PHI Income

• Capacity expansion delayed

• Unprecedented Consultant Recruitment & Retention Crisis

o Type A tried 2008 & 2011 and failed

o Current Pay Inequality: 500+ vacancies

o Increased exodus & greater recruitment problems

o Deterioration in public hospital care

34

Conclusions

• A strategy or plan which is based on ideology over pragmatism and focuses on the symptoms rather than the root cause problems is damaging and deflects from addressing the real problems.

• Capacity deficits need to be addressed.

• Let’s focus on fixing the real problems.

35

Thank You

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